Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 852550 (X3) Date Survey Completed 06/09/2022
Name of Provider or Supplier Dublin Kidney Institute Street Address, City, State 207 Industrial Blvd Ste 2, Dublin, GA
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
V0516 PA-FREQUENCY-INITIAL-30 DAYS/13 TX
CFR(s): 494.80(b)(1)

An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session.


This STANDARD is not met as evidenced by:
Based on a review of medical records and staff interview, it was determined that the facility failed to complete a comprehensive interdisciplinary assessment that was conducted by the entire interdisciplinary team (IDT) within 30 calendar days of admission or after 13 dialysis treatments for one of one sampled new patient (P#1), who was admitted on 3/23/22. This failure had the potential to negatively affect the health and safety of P#1. The facility census was 16 Peritoneal Dialysis (PD) patients and one Home Hemodialysis (HHD) patient. A review of P#1's medical records revealed the following: - P#1 was admitted to this facility on 3/23/22. There was no documentary evidence that a comprehensive IDT initial assessment was completed. There was an incomplete assessment by the Registered Nurse (RN BB), and Social Worker (SW), with no dates, and no signatures from both disciplines. There was no documentary evidence of the Registered Dietitian's assessment nor of the Nephrologist's assessment. A review of facility records revealed that there was no facility Policy and Procedures (P & P) regarding comprehensive IDT Assessments, except for a checklist, with a header, "Medical Record Audit". ... RN Assessment... complete RN assessment completed within 30 days. Assessment updated if treatment modality changes/as needed. Psychosocial/SW assessment - within 30 days of admission. Annually. Assessment updated if treatment modality changes/as needed. Nutrition Assessment - within 30 days of admission. Annually. Assessment updated if treatment modality changes/as needed. - Registered Nurse (RN AA) stated on 6/9/22 at approximately 4:00 p.m., that she could not find any documentary evidence of an initial comprehensive IDT assessment completed for P#1.